Oncologic surveillance intensity after endoscopic treatment of upper tract urothelial carcinoma.

BACKGROUND: The optimal oncologic surveillance in patients with upper tract urothelial carcinoma (UTUC) elected for conservative treatment is still a matter of debate. METHODS: Patients elected for endoscopic treatment of UTUC were followed up according to EAU guidelines recommendations after treatment. Bladder cancer recurrence-free survival (BCa-RFS), UTUC recurrence-free survival (UTUC-RFS), radical nephroureterectomy-free survival (RNU-FS), and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. The crude risks of BCa and UTUC recurrences over time were estimated with the Locally Weighted Scatterplot Smoothing method. RESULTS: Overall, 54 and 55 patients had low- and high-risk diseases, respectively. Median follow-up was 46.9 (IQR: 28.7-68.7) and 36.9 (IQR: 19.8-60.1) months in low and high-risk patients, respectively. In low-risk patients, BCa recurrence risk was more than 20% at 24 months follow-up. At 60 months, time point after which cystoscopy and imaging should be interrupted, the risk of BCa recurrence and UTUC recurrence were 14% and 7%, respectively. In high-risk patients, the risk of BCa and UTUC recurrence at 36 months was approximately 40% and 10%, respectively. Conversely, at 60 months, the risk of bladder recurrence and UTUC recurrence was 28% and 8%, respectively. CONCLUSIONS: For low-risk patients, cystoscopy should be performed semi-annually until 24 months, while upper tract assessment should be obtained up to 60 months, as per current EAU guidelines recommendations. For high-risk patients, upper tract assessment should be intensified to semi-annually up to 36 months, then obtained yearly. Conversely, cystoscopy should be ideally performed semi-annually until 60 months and yearly thereafter.

Simultaneous Bilateral Video-Endoscopic Inguinal Lymphadenectomy for Penile Carcinoma: Surgical Setting, Feasibility, Safety, and Preliminary Oncological Outcomes.

INTRODUCTION: Inguinal lymph node dissection (ILND) plays an important role for both staging and treatment purposes in patients diagnosed with penile carcinoma (PeCa). Video-endoscopic inguinal lymphadenectomy (VEIL) has been introduced to reduce complications, and in those patients elected for bilateral ILND, a simultaneous bilateral VEIL (sB-VEIL) has also been proposed. This study aimed to investigate the feasibility, safety, and preliminary oncological outcomes of sB-VEIL compared to consecutive bilateral VEIL (cB-VEIL). MATERIAL AND METHODS: Clinical N0-2 patients diagnosed with PeCa and treated with cB-VEIL and sB-VEIL between 2015 and 2023 at our institution were included. Modified ILND was performed in cN0 patients, while cN+ patients underwent a radical approach. Intra- and postoperative complications, operative time, time of drainage maintenance, length of hospital stay and readmission within 90 days, as well as lymph node yield, were compared between the two groups. RESULTS: Overall, 30 patients were submitted to B-VEIL. Of these, 20 and 10 patients underwent cB-VEIL and sB-VEIL, respectively. Overall, 16 (80%) and 7 (70%) patients were submitted to radical ILND due to cN1-2 disease in the cB-VEIL and sB-VEIL groups, respectively. No statistically significant difference emerged in terms of median nodal yield (13.5 vs. 14, p = 0.7) and median positive LNs (p = 0.9). sD-VEIL was associated with a shorter operative time (170 vs. 240 min, p < 0.01). No statistically significant difference emerged in terms of intraoperative estimated blood loss, length of hospital stay, time to drainage tube removal, major complications, and hospital readmission in the cB-VEIL and sB-VEIL groups, respectively (all p > 0.05). CONCLUSIONS: Simultaneous bilateral VEIL is a feasible and safe technique in patients with PeCA, showing similar oncological results and shorter operative time compared to a consecutive bilateral approach. Patients with higher preoperative comorbidity burden or anesthesiological risk are those who may benefit the most from this technique.

To drain or not to drain in uro-oncological robotic surgery? A systematic review and meta-analysis.

INTRODUCTION: The aim of this study was to compare the perioperative outcomes of routine drainage insertion vs. no drainage in patients undergoing robot-assisted radical prostatectomy (RARP), robot-assisted partial nephrectomy (RAPN), and robot-assisted radical cystectomy (RARC). EVIDENCE ACQUISITION: A literature search was conducted through April 2022 using PubMed/Medline, Embase, and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. EVIDENCE SYNTHESIS: Eleven studies comprising 8447 RARPs and 1890 RAPNs met our inclusion criteria. Our search strategy did not identify any studies within the RARC framework. In RARP, patients without postoperative drainage had lower rate of postoperative ileus (OR 0.53, 95% CI: 0.38 to 0.74; P<0.001) and similar low-grade (Clavien 1-2, P=0.41) and high-grade (Clavien ≥3; P=0.85) complications, urinary leakage (P=0.07), pelvic hematoma (P=0.35), symptomatic lymphocele (P=0.13), fever (P=0.25), incisional hernia (P=0.31), reintervention (P=0.57), length of hospital stay (P=0.22), and readmission (P=0.74) compared with routinely drained patients. In RAPN, patients without postoperative drainage had shorter length of hospital stay (mean difference: -0.84 days, 95% CI: -1.06 to -0.63; P<0.001) and similar low-grade (P=0.94) and high-grade (P=0.31) complications, urinary leakage (P=0.49), hemorrhage (P=0.39), reintervention (P=0.69), and readmission (P=0.20) compared with routinely drained patients. CONCLUSIONS: In our study, patients without drainage had similar perioperative course to patients with prophylactic drain insertion after RARP and RAPN. Omission of drain insertion was associated with a lower rate of postoperative ileus for RARP and a shorter hospital stay for RAPN. In the era of robotic surgery, routine drain placement is no longer indicated in unselected patients.

Optimizing decision-making process of benign uretero-enteric anastomotic stricture treatment after radical cystectomy.

PURPOSE: To identify preoperative predictors of endo-urological treatment (EUT) failure while promoting a new diagnostic and therapeutic pathway for benign uretero-enteric anastomosis stricture (UES) management after radical cystectomy (RC). MATERIALS AND METHODS: We relied on a prospectively maintained database including 96 individuals (122 renal units) who developed a benign UES at our institution between 1990 and 2018. UES was classified into two different types according to morphology: FP1 (i.e., sharp or duckbill) and FP2 (i.e., flat or concave). EUT feasibility, success rate, as well as intra and postoperative complications were recorded. Uni- and multivariable logistic regression analysis (MVA) assessed for predictors of EUT failure. RESULTS: Overall, 78 (63.9%) and 32 (26.3%) cases were defined as FP1 and FP2, respectively. EUT was not feasible in 33 (27.1%) cases. After a median follow-up of 50 (IQR 5-240) months, successful treatment was reached only in 15/122 (12.3%) cases. EUT success rates raised when considering short (< 1 cm) (16.8%), FP1 morphology (16.7%) strictures, or the combination of these characteristics (22.4%). Overall, 5 (5.2%) cases had CD ≥ III complications. FP2 (OR: 1.91, 95%CI 1.21-5.31, p = 0.03) and stricture length ≥ 1 cm (OR: 9.08, 95%CI 2.09-65.71, p = 0.009) were associated with treatment failure at MVA. CONCLUSIONS: Endoscopic treatment for benign UES after RC is feasible but harbors a low success rate. Stricture length and radiological morphology of the stricture are related to endoscopic treatment failure. Surgeons should be aware of the stricture features during the preoperative decision-making process to choose the optimal candidate for endoscopic treatment.

Robot-assisted kidney transplantation: State of art. / Trasplante renal asistido por robot: estado actual.

OBJECTIVES: Nowadays, Robotic assistedkidney transplantation (RAKT) is considered a lessinvasive alternative to the Open Kidney Transplantation(OKT) with several advantages such as image magnification,3D vision and articulated instruments and with arelatively short learning curve for an experienced surgeon.RAKT has shown comparable outcomes with theOKT literature data in terms of surgical and functionalresults. RAKT may decrease the complication rate, meanhospital stay, postoperative pain, and also improve aestheticoutcomes. The aim of this study was to perform asystematic review of the literature on this novel approachof KT. MATERIALS AND METHODS: A systematic review was performed in accordance with the Preferred ReportingItems for Systematic Reviews and Meta-Analyses (PRISMA)statement. The search was conducted using the databases PubMed/Medline, including as outcomes: (1) indications, (2) step-by-step technique for RAKT, (3) RAKT in special cases (4) surgical and functional outcomes,and (5) future perspectives in RAKT. RESULTS: The indications for RAKT are expanding, sothat including obese recipients, graft with multiple vesselsand graft from deceased donor. To date, the two absolute contraindications to RAKT are patients unfitfor pneumoperitoneum and presenting advanced atheromatic plaques where vessel clamping could result challenging. As far as the outcomes, the surgical and functional results are in line with the OKT experience.Complication rate is low in RAKT, particularly in terms of arterial and venous thrombosis (1%), lymphocele (3%),ureteral stricture (2%), and wound infection (0.3%). Arobotic assisted kidney auto-transplantation (RAKAT) has been recently described, as novel approach in case of complex proximal benign ureteral stenosis. Despite great advances in this field, some limits still need to be approached such as the modality to main tain the graft to a constant low temperature ( <20 ºC) and to find the proper location of arteriotomy in advanced atheromatic disease without the tactile feedback. CONCLUSION: The present review has confirmed that RAKT is as safe and feasible as OKT with comparable surgical and functional results. Complication rate is lower in RAKT than OKT and the indications are expanding quickly. Furthermore, new technologies are being introduced in order to improve the surgical performances and to expand more the indications for robotic surgery.However, a prospective randomized study in order to compare RAKT versus OKT is still required.

OBJETIVO: Hoy en día, el trasplante de riñón asistido robótico (TRAR) se considera una alternativa menos invasiva al Trasplante Renal Abierto (TRA) con varias ventajas como la imagen magnificada 3D y los instrumentos articulados. Además, con curva de aprendizaje relativamente corta para cirujanos expertos. El TRAR ha demostrado resultados quirúrgicos y funcionales comparables con los publicados sobre el TRA. El TRAR parece que disminuye la tasa de complicaciones, la estancia hospitalaria, el dolor postoperatorio y todo ello mejorando los resultados estéticos. El objetivo de este estudio es realizar una revisión sistemática de la literatura sobre este abordaje quirúrgico para el trasplante renal.MATERIALES Y MÉTODOS: Se realizó una revisión sistemática de conformidad con la declaración de Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). La búsqueda se llevó a cabo utilizando las bases de datos PubMed/Medline, incluyendo como resultados: (1) indicaciones, (2) técnica paso a paso para TRAR, (3) TRAR en casos especiales, (4) resultados quirúrgicos y funcionales, y (5) perspectivas futuras en TRAR. RESULTADOS: Las indicaciones para TRAR se están expandiendo, de modo que incluyen receptores obesos, injerto con múltiples vasos e injerto de donante fallecido. Las dos contraindicaciones absolutas el TRAR son pacientes que no puedan tolerar el pneumoperitoneo y/o que presentan placas ateromatosas lo que podría dificultar el clampaje arterial. En cuanto a los resultados, los resultados quirúrgicos y funcionales están en línea con la experiencia de OKT. La tasa de complicaciones es baja en RAKT, particularmente en lo que se refiere a trombosis arterial y venosa (1%), linfocele (3%), estenosis ureteral (2%), infección de herida quirúrgica (0,3%). Recientemente, se ha descrito el auto-trasplante renal asistido robótico como abordaje novedoso en caso de estenosis ureteral benigna compleja y localización proximal. A pesar de los grandes avances en este campo, todavía hay que abordar algunos límites comola dificultad para mantener el injerto renal a una temperatura baja constante (<20ºC) y cómo elegir el sitioa decuado donde realizar la arteriotomía en pacientes con enfermedad ateromatosa avanzada, ante la imposibilidad de palpar la arteria.CONCLUSIÓN: La presente revisión ha confirmado que TRAR es tan seguro y reproducible como el TRA con resultados quirúrgicos y funcionales comparables. La tasa de complicaciones es más baja en el TRAR y las indicaciones se están expandiendo rápidamente. Además, se están introduciendo nuevas tecnologías y nuevos dispositivos con el fin de mejorar el rendimiento quirúrgico y ampliar aun más las indicaciones para la cirugía robótica. Sin embargo, no existe y quizás sea necesario un estudio prospectivo aleatorizado para comparar los 2 abordajes.

Robot-assisted kidney transplantation: state of art / Trasplante renal asistido por robot: estado del arte

Objetives: Nowadays, Robotic assisted kidney transplantation (RAKT) is considered a lessinvasive alternative to the Open Kidney Transplantation(OKT) with several advantages such as image magnification, 3D vision and articulated instruments and with arelatively short learning curve for an experienced surgeon. RAKT has shown comparable outcomes with theOKT literature data in terms of surgical and functionalresults. RAKT may decrease the complication rate, meanhospital stay, postoperative pain, and also improve aesthetic outcomes. The aim of this study was to perform asystematic review of the literature on this novel approachof KT.Materials and methods: A systematic review wasperformed in accordance with the Preferred ReportingItems for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search was conducted using the databases PubMed/Medline, including as outcomes: (1) ndications, (2) step-by-step technique for RAKT, (3) RAKTin special cases (4) surgical and functional outcomes,and (5) future perspectives in RAKT.Results: The indications for RAKT are expanding, sothat including obese recipients, graft with multiple vessels and graft from deceased donor. To date, the twoabsolute contraindications to RAKT are patients unfitfor pneumoperitoneum and presenting advanced atheromatic plaques where vessel clamping could resultchallenging. As far as the outcomes, the surgical andfunctional results are in line with the OKT experience.Complication rate is low in RAKT, particularly in terms ofarterial and venous thrombosis (1%), lymphocele (3%),ureteral stricture (2%), and wound infection (0.3%). Arobotic assisted kidney auto-transplantation (RAKAT) hasbeen recently described, as novel approach in caseof complex proximal benign ureteral stenosis. Despitegreat advances in this field, some limits still need to beapproached such as the modality to maintain the graftto a constant low temperature (< 20 ºC) and to find the...(AU)

Objetivo: Hoy en día, el trasplante deriñón asistido robótico (TRAR) se considera una alternativa menos invasiva al Trasplante Renal Abierto (TRA) convarias ventajas como la imagen magnificada 3D y losinstrumentos articulados. Además, con curva de aprendizaje relativamente corta para cirujanos expertos. ElTRAR ha demostrado resultados quirúrgicos y funcionales comparables con los publicados sobre el TRA. ElTRAR parece que disminuye la tasa de complicaciones,la estancia hospitalaria, el dolor postoperatorio y todoello mejorando los resultados estéticos. El objetivo deeste estudio es realizar una revisión sistemática de laliteratura sobre este abordaje quirúrgico para el trasplante renal.Materiales y métodos: Se realizó una revisión sistemática de conformidad con la declaración de PreferredReporting Items for Systematic Reviews and Meta-Analyses (PRISMA). La búsqueda se llevó a cabo utilizando lasbases de datos PubMed/Medline, incluyendo como resultados: (1) indicaciones, (2) técnica paso a paso paraTRAR, (3) TRAR en casos especiales, (4) resultados quirúrgicos y funcionales, y (5) perspectivas futuras en TRAR.Resultados: Las indicaciones para TRAR se están expandiendo, de modo que incluyen receptores obesos,injerto con múltiples vasos e injerto de donante fallecido. Las dos contraindicaciones absolutas el TRAR sonpacientes que no puedan tolerar el pneumoperitoneoy/o que presentan placas ateromatosas lo que podríadificultar el clampaje arterial. En cuanto a los resultados, los resultados quirúrgicos y funcionales están enlínea con la experiencia de OKT. La tasa de complicaciones es baja en RAKT, particularmente en lo que se refiere a trombosis arterial y venosa (1%), linfocele (3%),estenosis ureteral (2%), infección de herida quirúrgica(0,3%). Recientemente, se ha descrito el auto-trasplante renal asistido robótico como abordaje novedoso en...(AU)

Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma: Oncologic Outcomes and Prognostic Factors in a Contemporary Cohort.

Introduction: Appropriate risk stratification and complete tumor ablation are the key factors to optimize the oncologic outcomes of patients undertaking endoscopic management for upper urinary tract urothelial carcinoma (UTUC). We aimed to identify risk factors associated to tumor recurrence and progression in a contemporary cohort of patients diagnosed and treated with the latest endourologic technologies. Patients and Methods: Forty-seven patients were selected between January-2015 and March-2019 for an endoscopic management of UTUC. Last generation of digital ureteroscopes with image-enhancing technologies were used for the detection of the lesions. The retrograde approach was the most frequent access (n = 45/47). The confocal laser endomicroscopy and multiple biopsy devices were variably used according to site and tumor presentation for their characterization. Holmium and Thulium lasers were variably used, with their combination being the preferred approach in case of larger lesions. Primary endpoints included the identification of factors associated with UTUC recurrence and progression, and bladder tumor recurrence. Results: Median follow-up (FU) was 24 months (interquartile range 17-44). On multivariate analysis, bladder cancer (BC) recurrence was associated to previous contralateral UTUC (hazard ratios: 5.08 confidence interval [95% CI: 1.35-18.94], p < 0.05) and tumor size (hazard ratios: 1.07 [95% CI: 1.00-1.14], p < 0.05). UTUC recurrence was associated to incomplete clearance after primary treatment (hazard ratios: 4.99 [95% CI: 1.15-21.62], p < 0.05), while UTUC progression was significantly related to the number of UTUC recurrences (hazard ratios: 3.10 [95% CI: 1.27-7.53], p < 0.05). No significant survival differences in BC/UTUC recurrence, as well as in UTUC progression, were detected between risk groups. No Clavien-Dindo grade >2 were detected; one patient developed ureteric stricture at 7-month FU. Limitations involve retrospective nature of the study and relatively small number of patients. Conclusions: The appropriate use of latest technology may enhance the oncologic outcomes of the endoscopic management of UTUC without compromising the safety of the approach. Among the prognostic factors identified in our series, UTUC recurrence seems to be associated to disease progression.

Endoscopic exploration directly impacts clinical decision making in the management of patients with suspected upper tract urothelial carcinoma following radical cystectomy.

OBJECTIVES: To assess whether the use of endoscopic exploration (EE) as a routine diagnostic tool in patients with clinical suspicion of upper tract urothelial carcinoma (UTUC) following radical cystectomy (RC) significantly impacts management decision-making and to describe the oncological outcomes of patients with UTUC after RC. MATERIALS AND METHODS: We performed a retrospective review of medical records of patients with suspicion of UTUC after RC between 2000 and 2019. Patient demographics, clinicopathological features, treatments, and outcomes were analyzed. RESULTS: We identified 60 patients with suspicion of UTUC. After diagnostic work-up, 16 were submitted to radical nephroureterectomy (RNU) and 44 underwent diagnostic EE. After EE, a further 18/44 (40.9%) were submitted to RNU, while no evidence of tumor was found in 12 (27.3%) and the remaining 12 (27.3%) underwent endoscopic treatment (ET). Thus, in 24/44 (54.5%) patients the primary treatment strategy, i.e., RNU, was altered. Twenty-nine (85.3%) of the 34 patients who underwent RNU had high-grade tumors and 16 (47%) had the muscle-invasive disease. In the ET group, 6 (50%) had high-grade tumors and 10 (83.4%) had tumors less than 2 cm. The 5-year estimated recurrence-free survival and cancer-specific survival were, respectively, 58.4% and 45.6% in the RNU group and 25% and 80.8% in the ET group. CONCLUSION: EE significantly impacts clinical decision-making in patients with suspicion of UTUC after RC, resulting in a change in treatment strategy in approximately half of the patients. UTUC following RC has a poor prognosis and although RNU is the gold standard, ET could be considered in a selected group of patients.

[Prostate cancer and COVID-19 pandemia: Current recommendations.] / Cáncer de próstata y la pandemia Covid-19. Recomendaciones ante una nueva realidad.

OBJECTIVE: The objective of this publicationis to provide recommendations in the management of prostate cancer (PC) in a new reality framework based on the presence of COVID-19 disease. MATERIAL AND METHODS: The document is based on the scarce evidence on SARS/Cov-2 and the experience of the authors in handling COVID-19 in their institutions, including specialists from Andalusia, Cantabria, Catalonia, Madrid and the Valencian Community. RESULTS: The authors defined different priorities for the different clinical situations in PC. Emergency/urgency (life-threatening or urgent even in normal situation), highpriority/elective urgency (potentially dangerous if postponed for more than 1 month), intermediate/electivepriority (it is recommended not to delay more than 6 months), low priority/delayed (can be postponed more than 6 months). According to this classification, the working panel agreed on the distribution of the different diagnostic, therapeutic and follow-up scenarios for PC. The risk of severe morbidity as a result of SARS-CoV-2 infection may out weigh the risk of PC morbidity/mortalityin many men; therefore, in the short term it is unlikely that delays in diagnosis or treatment can led to worse cancer outcomes. CONCLUSIONS: The COVID-19 pandemic has resulted in a challenge for our health system, which raises several considerations in the treatment of patients with PC. The redistribution of surgical procedures according to the degrees of priority is essential during the period of the pandemic and the transition to the new normality. The change of the out-clinics with the adequate security measures for healthcare practitioners and patients, andt he development of a telemedicine program is highly recommended.

OBJETIVO: El objetivo de esta publicaciónes proporcionar recomendaciones en el manejo del cáncer de próstata (CP) en el marco de la nueva realidad que supone la presencia de la COVID-19.MATERIALES Y MÉTODOS: El documento se basa en la escasa evidencia sobre SARS/CoV-2 y la experiencia de los autores en el manejo de la COVID-19 en sus instituciones incluyendo especialistas de Andalucía, Cantabria, Cataluña, Madrid y Comunidad Valenciana. RESULTADOS: Los autores definieron diferentes prioridades para los distintos supuestos clínicos en CP. Emergencia/urgencia (riesgo vital o urgencia aún en situación de normalidad), alta prioridad/urgencia electiva (potencialmente peligrosa si se pospone más de 1mes), prioridad intermedia/electiva (se recomienda no retrasar más de 6 meses), baja prioridad/demorable (se puede posponer más de 6 meses). Acorde a esta clasificación, el grupo de trabajo consensuó la distribución de los diferentes escenarios diagnósticos, terapéuticos y de seguimiento del CP. El riesgo de morbilidad grave como resultado de la infección por SARS-CoV-2puede superar el riesgo de morbi-mortalidad por CP en muchos hombres; por lo tanto, a corto plazo es pocoprobable que los retrasos en el diagnóstico o tratamiento conduzcan a peores resultados oncológicos. CONCLUSIONES: La pandemia COVID-19 ha resultado en un desafío para nuestro sistema de salud, lo que plantea varias consideraciones en el tratamiento de pacientes con CP. La planificación de los procedimientos quirúrgicos en función de los grados de prioridades imprescindible durante el periodo de pandemia y transición a la nueva normalidad. La reorganización de las consultas incluyendo la adaptación a las medidas de seguridad para profesionales y pacientes y el desarrollo de un programa de telemedicina es altamente recomendable.

Cáncer de próstata y la pandemia Covid-19. Recomendaciones ante una nueva realidad / Prostate cancer and COVID-19 pandemia: Current recommendations

OBJETIVO: El objetivo de esta publicaciónes proporcionar recomendaciones en el manejo del cáncer de próstata (CP) en el marco de la nueva realidad que supone la presencia de la COVID-19. MATERIALES Y MÉTODOS: El documento se basa en la escasa evidencia sobre SARS/CoV-2 y la experiencia de los autores en el manejo de la COVID-19 en sus instituciones incluyendo especialistas de Andalucía, Cantabria, Cataluña, Madrid y Comunidad Valenciana. RESULTADOS: Los autores definieron diferentes prioridades para los distintos supuestos clínicos en CP. Emergencia/urgencia (riesgo vital o urgencia aún en situación de normalidad), alta prioridad/urgencia electiva (potencialmente peligrosa si se pospone más de 1mes), prioridad intermedia/electiva (se recomienda no retrasar más de 6 meses), baja prioridad/demorable (se puede posponer más de 6 meses). Acorde a esta clasificación, el grupo de trabajo consensuó la distribución de los diferentes escenarios diagnósticos, terapéuticos y de seguimiento del CP. El riesgo de morbilidad grave como resultado de la infección por SARS-CoV-2puede superar el riesgo de morbi-mortalidad por CP en muchos hombres; por lo tanto, a corto plazo es pocoprobable que los retrasos en el diagnóstico o tratamiento conduzcan a peores resultados oncológicos. CONCLUSIONES: La pandemia COVID-19 ha resultado en un desafío para nuestro sistema de salud, lo que plantea varias consideraciones en el tratamiento de pacientes con CP. La planificación de los procedimientos quirúrgicos en función de los grados de prioridades imprescindible durante el periodo de pandemia y transición a la nueva normalidad. La reorganización de las consultas incluyendo la adaptación a las medidas de seguridad para profesionales y pacientes y el desarrollo de un programa de telemedicina es altamente recomendable

OBJECTIVE: The objective of this publication is to provide recommendations in the management of prostate cancer (PC) in a new reality framework based on the presence of COVID-19 disease. MATERIAL AND METHODS: The document is based on the scarce evidence on SARS/Cov-2 and the experience of the authors in handling COVID-19 in their institutions, including specialists from Andalusia, Cantabria, Catalonia, Madrid and the Valencian Community. RESULTS: The authors defined different priorities for the different clinical situations in PC. Emergency/urgency (life-threatening or urgent even in normal situation), high priority/elective urgency (potentially dangerous if postponed for more than 1 month), intermediate/elective priority (it is recommended not to delay more than 6 months), low priority/delayed (can be postponed more than 6 months). According to this classification, the working panel agreed on the distribution of the different diagnostic, therapeutic and follow-up scenarios for PC. The risk of severe morbidity as a result of SARS-CoV-2 infection may outweigh the risk of PC morbidity/mortality in many men; therefore, in the short term it is unlikely that delays in diagnosis or treatment can led to worse cancer outcomes. CONCLUSIONS: The COVID-19 pandemic has resulted in a challenge for our health system, which raises several considerations in the treatment of patients with PC. The redistribution of surgical procedures according to the degrees of priority is essential during the period of the pandemic and the transition to the new normality. The change of the out-clinics with the adequate security measures for healthcare practitioners and patients, and the development of a telemedicine program is highly recommended

Current role of robotic bladder cancer surgery.

INTRODUCTION: Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in urology, that is not devoid of postoperative complications. Minimally invasive surgery, and especially robot-assisted RC (RARC) has emerged as an alternative to open RC (ORC) in an attempt to minimize surgical morbidity and facilitate the surgical approach. The aim of this paper was to present the current knowledge on the oncological efficacy and complication outcomes of RARC. EVIDENCE ACQUISITION: A non-systematic review on all relevant studies with the keywords "Radical cystectomy," "Open," "Robot-assisted," "Complications," "Recurrence," "Survival," "Neobladder," "Potency," "Continence" and "Intracorporeal" was performed using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) Guidelines. EVIDENCE SYNTHESIS: RARC shows similar lymph node yields and positive surgical margin rates as well as perioperative complication outcomes compared with ORC. RARC exhibits significantly less blood loss and less intra- and postoperative blood transfusion. Moreover, survival and recurrence rates are not related to the surgical approach. Finally, RARC seems to be more expensive and has a longer operating time compared to the open technique. CONCLUSIONS: As current evidence shows, RARC seems as a technically feasible and safe procedure, providing equivalent perioperative and oncological results compared to ORC. More prospective, randomized-controlled trials are necessary to draw definitive conclusions on all comparative aspects.

Robotic radical cystectomy.

OBJECTIVES: Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in Urology. Several retrospective and prospective studies have demonstrated that robotic-assisted RC (RARC) represents a minimally invasive alternative to open surgery, showing non-inferiority in mid-term oncological outcomes. Moreover, important advantages related with  perioperative complications have also been published. The aim of this article is to describe RARC surgical steps and to review the most relevant ndings in the eld of RARC, focusing on its strengths and weaknesses when compared with open RC. METHODS: We performed a detailed step-by-step description of the RARC surgical technique, paying particular attention to its specific surgical details and adding our tips and tricks for an out standing performance. We also conducted a review of the most relevant articles in literature in terms of oncological, pathological and perioperative results. All these findings have been compared with the classical open radical cystectomy (ORC) technique. RESULTS: None of the studies published have demonstrated RARC to have worse oncological outcomes (PSM,RFS, CSS, OS) compared to ORC. RARC shows a decrease in blood loss and transfusion rates. No differences have been observed in complications rate, length of hospital stay, quality of life, and time to bowel movement between both approaches. The two disadvantages of RARC compared to ORC are a longer operative time and increased cost. Operating time can be reduced with surgeons gaining experience and technique standardization. The cost disparities and operative time between ORC and RARC at high-volume academic centers are less pronounced than in the general medical community. CONCLUSIONS: RARC is a technically feasible and safe approach, with oncological, pathological and perioperative results, at least, equivalent to ORC.

ARTICULO SOLO EN INGLES.OBJETIVO: La cistectomía radical (CR) esuno de los procedimientos quirúrgicos más complejosy con mayor morbilidad. Varios estudios retrospectivosy prospectivos han demostrado que la CR asistida porrobot (CRAR) representa una alternativa mínimamente invasivaa la cirugía abierta, mostrando no inferioridad enlos resultados oncológicos a medio plazo. Además, sehan publicado importantes ventajas en relación con lascomplicaciones peroperatorias. El objetivo de este artículoes describir los pasos quirúrgicos de la CRAR y revisarlos hallazgos más relevantes en el campo de la CRAR,focalizando en sus fortalezas y debilidades cuando secomparan con la CR abierta. MÉTODOS: Realizamos una descripción paso a paso,detallada, de la técnica quirúrgica de CRAR, poniendoparticular atención a sus detalles quirúrgicos específicos yañadiendo nuestros trucos y consejos para una ejecución excelente. También realizamos una revisión de los artículos más relevantes de la literatura en términos de resultadosoncológicos, patológicos y peroperatorios. Todosestos hallazgos se han comparado con los de la técnicaclásica de cistectomía radical abierta (CRA). RESULTADOS: Ninguno de los estudios publicados hademostrado que la CRAR tenga peores resultados oncológicos(márgenes quirúrgicos positivos, supervivencia librede recurrencia, cáncer específica y global) en comparación con la CRA. La CRAR muestra un descenso del sangradoy las tasas de transfusión. No se han observadodiferencias entre ambos abordajes en las tasas de complicaciones,estancias hospitalarias, calidad de vida y eltiempo hasta la deposición. Dos desventajas de la CRARen comparación con la CRA son el tiempo operatoriomás largo y el aumento del coste. El tiempo operatorio puede reducirse con el aumento de la experiencia de loscirujanos y la estandarización de la técnica. Las disparidadesen los costes y la duración de la cirugía son menospronunciadas en centros académicos de gran volumen que en los de la comunidad médica general. CONCLUSIONES: La CRAR es un abordaje técnicamentefactible y seguro, con resultados oncológicos, patológicosy peroperatorios, al menos, equivalentes a los dela CRA.

Robotic radical cystectomy / Cistectomía radical robótica

Objectives: Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in Urology. Several retrospective and prospective studies have demonstrated that robotic-assisted RC (RARC) represents a minimally invasive alternative to open surgery, showing non-inferiority in mid-term oncological outcomes. Moreover, important advantages related with perioperative complications have also been published. The aim of this article is to describe RARC surgical steps and to review the most relevant ndings in the eld of RARC, focusing on its strengths and weaknesses when compared with open RC. Methods: We performed a detailed step-by-step description of the RARC surgical technique, paying particular attention to its specific surgical details and adding our tips and tricks for an outstanding performance. We also conducted a review of the most relevant articles in literature in terms of oncological, pathological and perioperative results. All these findings have been compared with the classical open radical cystectomy (ORC) technique Results: None of the studies published have demonstrated RARC to have worse oncological outcomes (PSM, RFS, CSS, OS) compared to ORC. RARC shows a decrease in blood loss and transfusion rates. No dif- ferences have been observed in complications rate, length of hospital stay, quality of life, and time to bowel movement between both approaches. The two disad- vantages of RARC compared to ORC are a longer oper- ative time and increased cost. Operating time can be re- duced with surgeons gaining experience and technique standardization. The cost disparities and operative time between ORC and RARC at high-volume academic cen- ters are less pronounced than in the general medical community. ConclusionS: RARC is a technically feasible and safe approach, with oncological, pathological and perioperative results, at least, equivalent to ORC

Objetivo: La cistectomía radical (CR) es uno de los procedimientos quirúrgicos más complejos y con mayor morbilidad. Varios estudios retrospectivos y prospectivos han demostrado que la CR asistida por robot (CRAR) representa una alternativa mínimamente invasiva a la cirugía abierta, mostrando no inferioridad en los resultados oncológicos a medio plazo. Además, se han publicado importantes ventajas en relación con las complicaciones peroperatorias. El objetivo de este artículo es describir los pasos quirúrgicos de la CRAR y revisarlos hallazgos más relevantes en el campo de la CRAR, focalizando en sus fortalezas y debilidades cuando se comparan con la CR abierta. Métodos: Realizamos una descripción paso a paso, detallada, de la técnica quirúrgica de CRAR, poniendo particular atención a sus detalles quirúrgicos específicos y añadiendo nuestros trucos y consejos para una ejecución excelente. También realizamos una revisión de los artículos más relevantes de la literatura en términos de resultados oncológicos, patológicos y peroperatorios. Todos estos hallazgos se han comparado con los de la técnica clásica de cistectomía radical abierta (CRA). Resultados: Ninguno de los estudios publicados ha demostrado que la CRAR tenga peores resultados oncológicos (márgenes quirúrgicos positivos, supervivencia libre de recurrencia, cáncer específica y global) en comparación con la CRA. La CRAR muestra un descenso del sangrado y las tasas de transfusión. No se han observado diferencias entre ambos abordajes en las tasas de complicaciones, estancias hospitalarias, calidad de vida y el tiempo hasta la deposición. Dos desventajas de la CRAR en comparación con la CRA son el tiempo operatorio más largo y el aumento del coste. El tiempo operatorio puede reducirse con el aumento de la experiencia de los cirujanos y la estandarización de la técnica. Las disparidades en los costes y la duración de la cirugía son menos pronunciadas en centros académicos de gran volumen que en los de la comunidad médica general. Conclusiones: La CRAR es un abordaje técnicamentefactible y seguro, con resultados oncológicos, patológicosy peroperatorios, al menos, equivalentes a los dela CRA

Prospective evaluation of the performances of narrow-band imaging flexible videoscopy relative to white-light imaging flexible videoscopy, in patients scheduled for transurethral resection of a primary NMIBC.

PURPOSE: To evaluate on a lesion-by-lesion basis Narrow-Band Imaging flexible videoscopy (NBI-FV) in the detection of cancer compared to White-Light Imaging flexible videoscopy (WLI-FV). METHODS: WLI-FV and NBI-FV were sequentially performed in patients scheduled for TURBT for primary bladder cancer. Suspicious findings were individually harvested and characterized under WLI-FV (suspicious/non-suspicious) and NBI-FV (5-point Likert scale) and pathology. The primary objective was to determine if NBI-FV informed at least 20% more cancer lesions than WLI-FV (Relative true-positive rate > 1.19). A minimum of 120 specimens was to be analyzed to reach 90% power. RESULTS: Of 147 specimens taken in 68 patients, 101 were found suspicious under WLI-FV and 64 (64/101, 63.4%) confirmed as cancer. Of the 46 lesions undetected by WLI-VF, 16 were found positive for cancer (16/46, 34.8%). For NBI-FV, a significant increase in positive samples was observed with increments in Likert scale (p < 0.0002). Relative true-positive rate was 1.22 (95% CI 1.12-1.39)-NBI-FV detected 22% more cancer lesions compared to WLI-FV. Relative false-positive rate was 1.35 (95% CI 1.19-1.59). CONCLUSION: Researching alterations in mucosa and microvasculature by narrow-band imaging flexible videoscopy augmented by 22% the detection of cancer foci and contributed to the objective of complete resection of all visible lesions. Conversely, it entailed a 35% increase in false-positive results compared to white-light imaging, although the structured analysis of narrow-band imaging findings might be used to grade suspicion according to the Likert scale and balance the risk of a false-positive result to the benefit of demonstrating cancer.

The European Urology Residents Education Programme Hands-on Training Format: 4 Years of Hands-on Training Improvements from the European School of Urology.

BACKGROUND: The European School of Urology (ESU) started the European Urology Residents Education Programme (EUREP) in 2003 for final year urology residents, with hands-on training (HOT) added later in 2007. OBJECTIVE: To assess the geographical reach of EUREP, trainee demographics, and individual quality feedback in relation to annual methodology improvements in HOT. DESIGN, SETTING, AND PARTICIPANTS: From September 2014 to October 2017 (four EUREP courses) several new features have been applied to the HOT format of the EUREP course: 1:1 training sessions (2015), fixed 60-min time slots (2016), and standardised teaching methodology (2017). The resulting EUREP HOT format was verified by collecting and prospectively analysing the following data: total number of participants attending different HOT courses; participants' age; country of origin; and feedback obtained annually. RESULTS AND LIMITATIONS: A total of 796 participants from 54 countries participated in 1450 HOT sessions over the last 4 yr. This included 294 (20%) ureteroscopy (URS) sessions, 237 (16.5%) transurethral resection (TUR) sessions, 840 (58%) basic laparoscopic sessions, and 79 (5.5%) intermediate laparoscopic sessions. While 712 residents (89%) were from Europe, 84 (11%) were from non-European nations. Of the European residents, most came from Italy (16%), Germany (15%), Spain (15%), and Romania (8%). Feedback for the basic laparoscopic session showed a constant improvement in scores over the last 4 yr, with the highest scores achieved last year. This included feedback on improvements in tutor rating (p=0.017), organisation (p<0.001), and personal experience with EUREP (p<0.001). Limitations lie in the difficulties associated with the use of an advanced training curriculum with wet laboratory or cadaveric courses in this format, although these could be performed in other training centres in conjunction with EUREP. CONCLUSIONS: The EUREP trainee demographics show that the purpose of the course is being achieved, with excellent feedback reported. While European trainees dominate the demographics, participation from a number of non-European countries suggests continued ESU collaboration with other national societies and wider dissemination of simulation training worldwide. PATIENT SUMMARY: In this paper we look at methodological improvements and feedback for the European Urology Residents Education Programme hands-on-training over the last 4 yr.

[Surgical treatment of local disease in metastatic prostate cancer.] / Tratamiento quirúrgico de la enfermedad local en cáncer de prástata metastásico.

OBJECTIVES: Metastatic prostate cancer is a very heterogeneous disease with several treatment options. In some cases of oligometastatic disease, local treatment of the primary tumor complemented by metastasis directed therapy seems to improve oncological results. The objectives of this study are to define and understand oligometastatic prostate cancer, to show the usefulness and rationale of cytoreductive surgery in this scenario and to review all published studies about radical prostatectomy in patients with initially metastatic prostate cancer. METHODS: We performed a Pubmed bibliographic search using the keywords: prostate cancer, metastatic, oligometastatic, local treatment, radical prostatectomy, and cytoreductive surgery. We included all published works on radical prostatectomy in initially metastatic patient. Furthermore, we reviewed published articles about cytoreductive surgery and biology of the oligometastatic disease in journals of different medical specialties. RESULTS: Oligometastatic prostate cancer is recognized as an intermediate clinical stage between local and disseminated disease that seems to benefit from local treatment of the primary tumor plus metastasis directed treatment. In this scenario, different retrospective studies have demonstrated that radical prostatectomy diminishes local complication rate and improves oncological results without increasing morbidity. Currently, there is no consensus definition about the number, location, and imaging techniques to employ to consider a patient oligometastatic. Thus, it is difficult to compare the results of the different studies and identification of a subgroup of patients that could benefit from this local treatment. CONCLUSIONS: In absence of prospective randomized data, radical prostatectomy seems to be useful for local treatment of the primary tumor in a selected group of patients with oligometastatic prostate cancer.

Tratamiento quirúrgico de la enfermedad local en cáncer de próstata metastásico / Surgical treatment of local disease in metastatic prostate cancer

OBJETIVO: El cáncer de próstata metastásico es una enfermedad muy heterogénea con varias opciones de tratamiento. En algunos casos de enfermedad oligometastásica el tratamiento local del tumor primario acompañado de terapia dirigida de las metástasis parece que puede mejorar los resultados oncológicos. Los objetivos de este estudio son definir y entender el cáncer de próstata oligometastásico, ver la utilidad y justificación de la cirugía citorreductora en este escenario y revisar todos los estudios que se han publicado sobre prostatectomía radical en pacientes con cáncer de próstata metastásico inicial. MÉTODOS: Se realizó una búsqueda bibliográfica en Pubmed usando las palabras clave: cáncer de próstata, metastásico, oligometastásico, tratamiento local, prostatectomía radical y cirugía citorreductora. Se incluyeron todos los trabajos publicados hasta la fecha de prostatectomía radical en paciente metastásico inicial. Además, se revisaron artículos publicados en revistas de distintas especialidades médicas y ciencias básicas que trataban sobre cirugía citorreductora y biología de la enfermedad oligometastásica. RESULTADOS: El cáncer de próstata oligometastásico se reconoce como un estadio clínico intermedio entre la enfermedad local y la diseminada que parece beneficiarse de un tratamiento local del tumor primario y dirigido de las metástasis. En este escenario, los distintos estudios retrospectivos han demostrado que la prostatectomía radical disminuye la tasa de complicaciones locales y mejora los resultados oncológicos sin aumentar la morbilidad. Actualmente, no existe consenso en definir el número, la localización y las técnicas de imagen a emplear para poder considerar un paciente oligometastásico. Por todo ello, resulta difícil la comparación de los resultados entre los distintos estudios y la identificación del subgrupo de pacientes que se pueden beneficiar de este tratamiento local. CONCLUSIONES: A falta de estudios prospectivos aleatorizados, la prostatectomía radical parece ser una opción válida para el tratamiento del tumor primario en algunos pacientes con cáncer de próstata oligometastásico

OBJECTIVES: Metastatic prostate cancer is a very heterogeneous disease with several treatment options. In some cases of oligometastatic disease, local treatment of the primary tumor complemented by metastasis directed therapy seems to improve oncological results. The objectives of this study are to define and understand oligometastatic prostate cancer, to showthe usefulness and rationale of cytoreductive surgery in this scenario and to review all published studies about radical prostatectomy in patients with initially metastatic prostate cancer. METHODS: We performed a Pubmed bibliographic search using the keywords: prostate cancer, metastatic, oligometastatic, local treatment, radical prostatectomy, and cytoreductive surgery. We included all published works on radical prostatectomy in initially metastatic patient. Furthermore, we reviewed published articles about cytoreductive surgery and biology of the oligometastatic disease in journals of different medical specialties. RESULTS: Oligometastatic prostate cancer is recognized as an intermediate clinical stage between local and disseminated disease that seems to benefit from local treatment of the primary tumor plus metastasis directed treatment. In this scenario, different retrospective studies have demonstrated that radical prostatectomy diminishes local complication rate and improves oncological results without increasing morbidity. Currently, there is no consensus definition about the number, location, and imaging techniques to employ to consider a patient oligometastatic. Thus, it is difficult to compare the results of the different studies and identification of a subgroup of patients that could benefit from this local treatment. CONCLUSIONS: In absence of prospective randomized data, radical prostatectomy seems to be useful for local treatment of the primary tumor in a selected group of patients with oligometastatic prostate cancer

Laparoscopic Management of Ureteroileal Anastomosis Strictures: Initial Experience.

BACKGROUND: A ureteroileal anastomosis stricture (UAS) is one of the most frequent complications after radical cystectomy. Open surgical repair is the treatment of choice but is associated with morbidity. OBJECTIVE: To describe the efficacy and safety of laparoscopic management for benign secondary UAS. DESIGN, SETTING, AND PARTICIPANTS: A review was performed of the 11 initial procedures performed at our academic center from December 2010 to December 2014, with mean follow-up of 38 mo (range 12-169). Patients included had benign ureteroileal strictures longer than 1cm. SURGICAL PROCEDURE: A pure laparoscopic approach was systematically used, involving a two-step procedure for left and a one-step procedure for right ureteral stenosis. MEASUREMENTS: Perioperative data were collected and complications were assessed using the Clavien-Dindo grading system. Outcomes and follow-up data were analyzed. RESULTS AND LIMITATIONS: A descriptive statistical analysis was performed for 11 surgeries in ten patients. The median stricture length was 2.4cm. No conversion to open surgery was required. The mean blood loss was 180ml and the mean hospital stay was 10 d. Early complications included limited lymphorrhea (n=1), limited anastomotic leakage (n=2), and accidental descent of a ureteral catheter (n=1) that was replaced with radiologic intervention. The mean follow-up was 38 mo (range 12-169). No late complications were reported. After 1 yr of follow-up, six patients had good glomerular filtration rates, all patients were asymptomatic, and no stenotic relapses were detected. CONCLUSIONS: This laparoscopic technique for the management of benign secondary UAS is feasible, with good results and without long-term complications. This minimally invasive approach reduces the morbidity associated with open surgery while retaining good success rates. PATIENT SUMMARY: We describe a novel laparoscopic approach for patients with a ureteroileal anastomosis stricture after radical cystectomy to avoid the complications associated with open surgery. The surgery was found to be viable and safe with good long-term results.

[Endoscopic bladder neck incision as first step in radical prostatectomy: An aid for patients previously treated for Bladder outlet obstruction]. / INCISIÓN ENDOSCÓPICA DEL CUELLO VESICAL COMO PRIMER PASO EN LA PROSTATECTOMÍA RADICAL: UNA AYUDA EN PACIENTES PREVIAMENTE OPERADOS POR HIPERPLASIA BENIGNA DE PRÓSTATA.

OBJECTIVE: Some patients with the indication of radical prostatectomy (RP) have often undergone previous surgical treatment for bladder outlet obstruction (BOO). These previous treatments make oncological surgery more challenging because of the difficulty in the identification of bladder neck and ureteral orifices. We present a new technique that entails previous endoscopic marking of bladder neck in order to make radical prostatectomy easier. METHODS: Twelve men with previous prostatic surgery for BOO underwent a laparoscopic/robotic radical prostatectomy between August 2008 and October 2012. The same technique was performed in all cases, a first circular endoscopic incision (EI) to mark the bladder neck and a second laparoscopic/robotic approach to complete the RP. We analyzed oncological and functional outcomes, as well as complications. RESULTS: Median operative time (EI + RP) was 175 minutes (140-205), being surgical time for endoscopic approach 20 minutes (17-31). No ureteral lesions were described and no ureteral stents were required. Positive margin rate was 8.3%. Only 1 of 5 complications observed needed surgery to be solved. Continence rate was 66.7% at one year of surgery. CONCLUSIONS: Our results show that a previous endoscopic bladder neck incision in patients with previous surgery for BOO makes easier the identification and dissection of the bladder neck itself during radical prostatectomy decreasing the risk of ureteral lesions as well as improving functional outcomes.